Minimally invasive tricuspid valve surgery

Early and mid-term outcomes of tricuspid valve surgery in patients with functional tricuspid regurgitation induced by atrial fibrillation

Background

The strategy of treatment for tricuspid regurgitation (TR) induced by atrial fibrillation (AF) has not been established. The aim of this study was to evaluate the outcomes of surgical treatment for TR induced by AF.

Methods

From 2000 to 2021, a total of 1,301 patients underwent tricuspid valve (TV) surgery. Among them 43 patients who diagnosed as AF induced TR were enrolled. The tricuspid valve-related events (TVRE) included cardiac death, TV reoperation, development of moderate or greater TV disease, congestive heart failure requiring re-admission, and major bleeding or thrombosis. The median follow-up duration was 42.0 months.

Results

The interval from diagnosis of AF to more than moderate TR was 61.2 months, and the interval from initial diagnosis of severe TR to surgery was 2.4 months. Concomitant Cox-maze III procedure was performed in 39 patients. The operative mortality occurred in 1 patient, and there was no permanent pacemaker implantation. Overall survival rates at 1- and 5-year were 90.6% and 79.3%, respectively. The cumulative incidence of TVRE at 1- and 5-year were 16.3% and 26.5%, respectively. The cumulative incidences of AF recurrence at 1- and 3-year in the patients with surgical ablation were 29.7% and 67.6%. The TVRE was significantly associated with the longer interval from diagnosis of severe TR to surgery (hazard ratio: 1.023, 95% confidence interval: 1.005-1.042).

Conclusions

TV surgery for TR induced by AF showed low surgical mortality and favorable mid-term outcomes. For these patients, early surgery after progress to severe TR can be helpful to decrease the occurrence of TVRE.

Valvular heart disease: from mechanisms to management

Valvular heart disease is common and its prevalence is rapidly increasing worldwide. Effective medical therapies are insufficient and treatment was historically limited to the surgical techniques of valve repair or replacement, resulting in systematic underprovision of care to older patients and those with substantial comorbidities, frailty, or left ventricular dysfunction. Advances in imaging and surgical techniques over the past 20 years have transformed the management of valvular heart disease. Better understanding of the mechanisms and causes of disease and an increasingly extensive and robust evidence base provide a platform for the delivery of individualised treatment by multidisciplinary heart teams working within networks of diagnostic facilities and specialist heart valve centres. In this Series paper, we aim to provide an overview of the current and future management of valvular heart disease and propose treatment approaches based on an understanding of the underlying pathophysiology and the application of multidisciplinary treatment strategies to individual patients.

Outcomes of minimally invasive isolated tricuspid valve repair and replacement through right mini-thoracotomy

Objective

Isolated tricuspid valve surgery is uncommon and associated with high perioperative morbidity and mortality. We aimed to study the overall outcomes of patients who underwent minimally invasive right thoracotomy tricuspid valve surgery (Mini-TVS), consisting of either tricuspid valve repair (TVre) or replacement (TVR).

Methods

We performed a retrospective analysis of all Mini-TVS procedures (2017-2022), through which we identified isolated tricuspid valve surgeries. We examined in-hospital outcomes, survival analysis over a 4-year period, and competing risk analysis for reoperative surgery.

Results

Among a total of 51 patients, the average age was 60 ± 16 years, and 67% (n = 34) were female. Severe tricuspid regurgitation was present in all cases. Infective endocarditis was noted in 7.8% (n = 4), and 24% (n = 12) had preexisting pacemakers. Mini-TVS included TVre in 18 patients (35%) and TVR in 33 patients (65%). The in-hospital and 30-day mortality rates were 4% (n = 2) and 6% (n = 3), respectively. At 4 years, the overall TVS survival was 76% (confidence interval, 62-93%), with no significant difference between TVre and TVR (91% vs 69%, P = .16). At follow-up, 3 patients required repeat surgery for recurrent regurgitation after 2.6, 3.3, and 11 months, with a reoperation rate of 7.3% (confidence interval, 2.4-22%) at 2 years. Factors associated with worse overall survival included nonelective surgery, right ventricular dysfunction, serum creatinine >2 g/dL, and concomitant left-sided valve disease.

Conclusions

A nonsternotomy minimally invasive approach is a feasible option for high-risk patients. Midterm outcomes were similar in repair or replacement. Patients with right ventricular dysfunction and left-sided disease had worse outcomes.

Contemporary Approach to Tricuspid Regurgitation: Knowns, Unknowns, and Future Challenges

Severe tricuspid regurgitation (TR) worsens heart failure and is associated with impaired survival. In daily clinical practice, patients are referred late, and tricuspid valve interventions (surgical or transcatheter) are underutilised, which may lead to irreversible right ventricular damage and increases risk. This article addresses the appropriate timing and modality for an intervention (surgical or transcatheter), and its potential benefits on clinical outcomes. Ongoing randomised controlled trials will provide further insights into the efficacy of transcatheter valve interventions compared with medical treatment.

Valvular Heart Failure due to Tricuspid Regurgitation: Surgical and Transcatheter Management Options

Given the independent association of mortality with higher grades of tricuspid regurgitation severity, there is an increasing interest in improving the outcomes of this prevalent valvular heart disease. A new classification of tricuspid regurgitation etiology allows for an improved understanding of different pathophysiologic forms of the disease, which may determine the appropriate management strategy. Current surgical outcomes remain suboptimal and multiple transcatheter device therapies are currently under investigation to give high and prohibitive surgical risk patients treatment options beyond medical therapy.

Minimal Access Tricuspid Valve Surgery

Tricuspid valve diseases are a heterogeneous group of pathologies that typically have poor prognoses when treated medically and are associated with significant morbidity and mortality with traditional surgical techniques. Minimal access tricuspid valve surgery may mitigate some of the surgical risks associated with the standard sternotomy approach by limiting pain, reducing blood loss, lowering the risk of wound infections, and shortening hospital stays. In certain patient populations, this may allow for a prompt intervention that could limit the pathologic effects of these diseases. Herein, we review the literature on minimal access tricuspid valve surgery focusing on perioperative planning, technique, and outcomes of minimal access endoscopic and robotic surgery for isolated tricuspid valve disease.

Contemporary Outcomes of Isolated Tricuspid Valve Surgery

INTRODUCTION

Isolated tricuspid valve (TV) surgery is uncommonly performed and has historically been associated with excessive operative mortality. We previously reported improved short-term outcomes at our center. Understanding contemporary outcomes of isolated TV surgery beyond the perioperative period is essential to properly benchmark outcomes of newer transcatheter interventions.

METHODS

Patients who underwent isolated TV surgery from 2007 to 2021 at a single institution were retrospectively reviewed. Survival was estimated using the Kaplan-Meier method and multivariable Cox proportional hazards regression modeling identified independent risk factors for all-cause mortality.

RESULTS

Among 173 patients undergoing isolated TV surgery, 103 (60%) underwent TV repair and 70 (40%) underwent TV replacement. Mean age was 60.3 ± 18.9 y and 55 (32%) were male. The most common etiology of TV disease was functional (46%). In-hospital mortality was 4.1% (7/173), with no difference between TV repair and replacement (P = 0.06). Overall survival at 1 y and 5 y was 78.3% (111/142) and 64.5% (53/82), respectively. After median (interquartile range) follow-up of 2.0 (0.6-4.4) y, patients undergoing TV repair experienced a higher unadjusted survival as compared to those undergoing TV replacement (log-rank P = 0.02). However, after adjusting for covariates, TV replacement was not an independent predictor of all-cause mortality (hazard ratio 1.40; 95% confidence interval, 0.71-2.76; P = 0.33).

CONCLUSIONS

Isolated TV surgery can be performed with lower operative mortality than historically reported. Establishing survival benchmarks from TV surgery is important in the era of developing transcatheter interventions.